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APPLICATION FOR PERMIT <br /> -^ SAN JOAQUIN LOCAL HEALTH DISTRICT 1J_ r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CAS <br /> I Telephone (209) 466-6781 <br /> i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Joh Address <br /> City Isit Lot Size PM <br /> I <br /> I <br /> Owner's Name Address Phone l <br /> I <br /> Contractor VIA LL Address 3 S 0 Wr CLIan J04icense No.� Phone S a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' <br /> r'] Public C] Other FI Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation --Approx. Depth 1 1 Eastern Surface Seal Installed by _ <br /> Repair Work'Done ❑ Type of Pump H.P.- State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') J (1 7 <br /> i Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION IJ DESTRUCTION [ septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence�CommercialOther I <br /> i <br /> Number of living units: Number of bedrooms <br /> i <br /> i Character of soil to a depth of 3 feet: Water table depth j <br /> I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r 4 k <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER SED t ❑ Distance to nearest: ',Well Foundation Property me <br /> I � a <br /> SEEPAGE PITS 1 I Depth I Size Number <br /> • <br />€ SUMPS Ll Distance to nearest: Well J <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ r 1 <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di1trict. i <br /> e owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> mploy person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the wing: "I ce at in the performance o rk for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cali i <br /> The applicant must c or a re _on e side. <br /> Tit <br /> Date: <br /> DEPARTMENT USE ONLY p <br /> Application Accepted by Date - "� _. Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ,❑ StkN_-466-6781. ❑.Lodi„369-3621—O-Menteca-823-71049:Tracy-835-6385--,V- <br /> Applicant <br /> ---- -Applicant- Return all copies to: Envifonmental Health Permit/Services 1601 E. Hazelton Ave.,'P.O.�Box 2009, Stk., CA 95201 <br /> FEE I <br /> CK tf <br /> F <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> a.EH 13-24{REV.t k sY /�/�-/ /�. r 9 <br /> EH 1428 V <br /> i <br />